2021 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
HealthPartners Journey Pace (PPO) (H4882-002-0) Benefit Details select insulin pay $35 copay | ||||||
This plan is available in Morrison County, MN Monthly Premium: $0.00 Rx Deductible: $300 Initial Coverage Limit: $4,130 Click on a letter below to view the HealthPartners Journey Pace (PPO) Formulary A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: Preferred Generic: | $8.00(E) | $8.00(E) | $8.00(E) | $24.00(E) | $24.00(E) | $16.00(E) |
Tier 2: Generic: | $14.00(E) | $14.00(E) | $14.00(E) | $42.00(E) | $42.00(E) | $28.00(E) |
Tier 3: Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: Non-Preferred Drug: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 5: Specialty Tier: | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $8.00 | $8.00 | $8.00 | $24.00 | $24.00 | $16.00 |
Tier 2: Generic: | $14.00 | $14.00 | $14.00 | $42.00 | $42.00 | $28.00 |
Tier 3: Preferred Brand: | $47.00 | $47.00 | $47.00 | $141.00 | $141.00 | $131.00 |
Tier 4: Non-Preferred Drug: | 35% | 35% | 35% | 35% | 35% | 35% |
Tier 5: Specialty Tier: | 27% | 27% | 27% | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 75% Generic and 75% Brand Donut Hole Discount applies | ||||||
All Formulary Generic Drugs: | 25% | 25% | 25% | 25% | 25% | 25% |
All Formulary Brand-Name Drugs: | 25% | 25% | 25% | 25% | 25% | 25% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $3.70 | The greater of 5% or $3.70 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $9.20 | The greater of 5% or $9.20 | ||||
Notes: *The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. (E) Drugs on this tier are excluded from the Initial Deductible and do not count toward meeting the deductible. | ||||||
Go to the HealthPartners Journey Pace (PPO) 2021 Formulary Browser by choosing a letter below: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 |